Deerswood Lodge

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 93 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

The management team demonstrated an exceptional approach to the culture, openness and transparency of the service. Without exception people, staff, relatives and professionals said the service had an open, inclusive and welcoming culture, where people using the service came first and their satisfaction was a priority. All staff followed a set of agreed values, which supported them to continually aspire to achieve good outcomes for people and led to high-quality care being delivered. A professional told us, “Over the 20+ years that I have been a [job title], I have dealt with many different care homes. Deerswood Lodge is by a long way the best home I have worked with, and I know my patients are well care for by their staff, and they are in very good safe hands. Lots of new patients come to the home and comment on how excellent the home is, which shows how well run it is. I regularly recommend Deerswood Lodge to patients and other people, as I know it is so well run. I feel lucky to work with a home that is run so well, and I can only give it a glowing report.”

Staff spoke with passion for providing outstanding outcomes for the people they supported and were proud of the difference they made to people's lives. We saw examples of staff supporting people gain in confidence, open up their world through connection with others and be fully involved in their life, home and the community they had built. One member of staff told us, “I’m proud to say I work here, because I know how well we care for everyone and how happy they are. We’re happy too.”

The service had a strong focus on how they could enable people to be fully involved in their life and care. The organisational culture fostered quality person-centred services, so that people could have a life well lived, and enabled people to be closely connected to their families, friends and community. This approach enabled people to feel safe and encouraged to try new things, take risks and not be limited by their environment or condition.
The provider had a clear shared vision, strategy and culture, which embraced diversity and was inclusive for all. The management team led by example, and staff understood the importance of upholding the values of the organisation. People’s human rights were fully embraced and supported. Policies and procedures had regard to equality and human rights, equity of care experiences, diversity and inclusion and the needs of people.

The provider had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders were visible, knowledgeable and supportive, and helped staff develop in their roles. The values of empowerment, individuality, respect, inclusiveness, and authenticity were embedded into everyday practices at the service. The service was led by an enthusiastic, motivated registered manager and senior management team. They were passionate about enabling the people at Deerswood Lodge to live their best lives. They acted as role models for the whole staff team, working alongside them to support people. Their strong visibility allowed staff to raise any issues or concerns as they arose, which were addressed immediately for the benefit of the people living there. The registered manager focussed on succession planning and talent management within the staff team. They told us, “We always look to help staff progress and learn within the home, we want them to succeed.” One member of staff told us, “[Registered manager] is the best manager I’ve had by far. It’s easy to discuss progression with management. We can request to observe other job roles to see if it is something we want to do." We saw how staff had been developed and supported to progress within the service. This support from leaders and encouragement of staff development and progression, had created a skilled and confident staff team. This promoted continuity of care and had significantly improved outcomes for people. In respect to management and the competence and confidence of staff, a health professional added, “I think Deerswood Lodge is very well run and this is thanks to an excellent management team and senior carers. They have a stable team, and [registered manager] is fantastic to work with. I have weekly contact with the senior carers. They all know their residents well and the issues they may be having, and we can have a good professional discussion on any issues concerning their care or health. They are confident with any plans we make, and very competent so I know things will happen as it should do.”

The provider was exceptional at fostering a positive culture where people knew they could speak up and their voice would be heard. Systems were in place to support staff to raise concerns, provide feedback and contribute to improvements within the service.

An open-door approach from the management team supported a transparent culture. Leaders were visible and approachable within the service, which helped staff feel comfortable seeking advice or raising concerns when needed. Posters and information displayed throughout the service encouraged staff to raise concerns, share ideas and provide feedback. Staff had access to a QR code to contact senior leaders directly, including anonymously if preferred. Leaders promoted an open culture and committed to responding to staff feedback and explaining any actions taken as a result. This system of accessible availability of senior leaders to staff had led to meaningful improvements within the service, including changes to staff uniforms to improve comfort and adaptations to the car park to improve safety and accessibility. Feedback from staff also resulted in creative community projects being initiated and events which promoted teamwork, inclusion and positive experiences for people living at the service. Opportunities to attend senior meetings, access organisational information and contribute to service development helped create a culture where staff felt valued, empowered and able to influence positive change.
Staff also had regular opportunities to speak openly through supervisions, team meetings and daily handovers. These meetings encouraged reflective discussions and ensured any concerns could be escalated appropriately. A member of staff told us, “We can raise anything we want to. We’re encouraged to. Anything we are concerned about, or anything that is good. The managers always listen to me”. There was a clear process for managing concerns and complaints. Records demonstrated that when issues were raised, they were investigated appropriately and learning was identified to drive improvements within the service.

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them.

Without exception staff felt respected, supported, and valued within all roles. Staff said they could raise any concerns without fear. They said the service continuously promoted equality and diversity in daily work and provided opportunities for development and career progression.

Deerswood Lodge had a strong multicultural identity, with staff from almost 20 different nationalities and people using the service from a wide range of cultural backgrounds. Staff were supported to observe cultural and religious commitments, which promoted wellbeing, inclusion and continuity of care. Cultural celebrations such, as Diwali and Eid, were recognised within the service. Regular “International Day” events were held, where residents chose a country to learn about and staff shared traditional food, music and cultural practices from their heritage. People, staff and visitors spoke positively about these events, which promoted inclusion, social engagement and meaningful experiences. Some activities and foods had become a regular part of the service’s menus and activity programme due to their popularity.
Staff were incredibly supportive of each other and worked collaboratively. The staff team displayed compassion, kindness, and empathy towards each other. One member of staff told us, “I love working here, we’re one big team. We support each other all the time, it doesn’t matter which part of the home you work in, we all help out.”

Staff had numerous opportunities to have input into the development of the service. They were able to share feedback during regular supervision meetings, staff meetings or directly with the registered manager on a one-to-one basis. Furthermore, staff ideas had been acted upon and had led to improvements within the service. The support staff offered to each other contributed to the staff team having a very positive morale. This led to a low turnover of staff which meant people were cared for by a consistent staff team who knew them very well.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Previous areas requiring improvement identified at the last inspection had been met in respect to systems of governance, quality monitoring and record keeping. Quality assurance processes were in place, designed to give an effective overview of quality of the service and identifying any shortfalls. The management at the service had implemented robust systems of governance and audit.
 

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.
Staff and leaders worked exceptionally well with local groups to ensure people using the service were part of their community. To enhance the quality and experience people received, leaders promoted collaborative ways of working with specialist services such as the community nursing team, occupational therapies, mental health services and other external professionals to support people’s needs. One health professional told us, “I think Deerswood Lodge is an excellent care home and looks after its residents very well. They are very caring and try and make sure every resident is treated as an individual. They always raise matters appropriately, and the care given is definitely safe and meeting the needs of the residents. They try to cater to individual requests, and I have never had any concerns about patient safety. They are well organised, caring and responsive to any issues whenever I deal with them”.
The provider worked locally with other stakeholders to drive improvement in the local care sector. A professional told us, “[Registered manager] is excellent, she always has an open door and takes the conditions seriously. I work with a lot of care homes and Deerswood Lodge is the most approachable. They always give me time and know their residents well.” Furthermore, the service had connections with local schools, colleges and charities. For example, children from the local primary school had worked with people and staff in the gardens to build a bug hotel, decorate stones and carry out ongoing projects that maintained the relationships that had been built.
The management and staff helped people stay connected with their local community and supported them to join groups that enriched their lives, but also developed bespoke in-house opportunities where this met people’s needs better. They actively sought out new opportunities for people to contribute to the local community. For example, the people and staff worked with local volunteers on a rewilding project in the gardens of the service to improve and connect green spaces in the local area and to encourage wildlife. People, staff, relatives, volunteers and local visitors were involved in developing themed gardens, growing flowers, fruit and vegetables, and taking part in gardening activities. Produce grown in the gardens was used in the service, with people supported to help prepare meals for themselves and visitors. The provider also organised fundraising activities and planting days involving local schools and the wider community. This helped create a strong sense of inclusion, purpose and connection for people living at the service. A member of staff told us, “We bring the outside into the home.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff were encouraged to develop their skills and learning so they could provide the most appropriate care for people using up to date best practice guidelines. For example, staff were allocated as ‘Champions’. These members of staff received in depth training around specific topics which included IPC, nutrition and hydration, medication, dementia, care planning and falls prevention. One health professional told us, “I am always impressed with Deerswood Lodge.The staff show empathy and respect. Customer safety is always a priority, as is confidentiality. The staff are very professional." The registered manager added, “We are lucky, we have comprehensive in-house training available. As managers we also learn from other homes and keep up to date with any developments.”